Incident Report Form

Log incidents, near-misses and hazards for your safety register.

Section 1 · Incident details

Date of incident

Time of incident

Location

Tour / Activity

Weather / Environmental

Type of incident

Severity

Minor (No treatment needed)

Moderate (First aid required)

Serious/Notifiable (Hospitalization or worse)

Description of incident

Section 2 · Involved parties

Name

Contact

Injuries / effects

Name

Contact

Injuries / effects

Name

Contact

Injuries / effects

Medical / health notes

Section 3 · Immediate response & actions taken

Stabilization

Emergency services contacted

Evacuation / rescue carried out

Resources used

First-Aid Kit

Emergency Phone/Satellite

Other

All participants accounted for (headcount confirmed)

Section 4 · Reporting

Safety officer notified at

Notifiable to WorkSafe NZ

Reported to other regulator

Participant / emergency contacts notified

Section 5 · Contributing factors & root cause

Section 6 · Follow-up & recommendations

Immediate corrective actions

Long-term improvements

Investigation assigned to

Review date

Section 7 · Signatures & declarations

Reported by · name

Role

Date

Reviewed by · name

Date reviewed

Comments

Sign-off

Name

Date

Signature

Draw your signature above using a mouse, stylus or finger.

Submits to the admin area under "Forms".

By submitting you confirm the information above is accurate.